Member: World Health Organisation Civil Society Reference Group on HIV

“Reckless sexual behaviour among gay teens and men” is being fuelled by the increasing use of PrEP. This claim rests on a conceptual misunderstanding and some factual errors.

I was alarmed to read the article titled Playing with fire (City Press, March 5 2017) on pre-exposure prophylaxis (PrEP) among gay men. It makes the claim that “reckless sexual behaviour among gay teens and men” is being fuelled by the increasing use of PrEP. This claim rests on a conceptual misunderstanding and some factual errors.

The conceptual misunderstanding is to equate sex without a condom among people who are on PrEP with “recklessness”. Accessing PrEP takes planning and resources.

In a context where many doctors are still uninformed about basic sexual health for gay men, never mind PrEP, it takes courage for gay men to bring it up with their doctors and make plans to access it.

Accessing PrEP means one must go for regular HIV testing (you can only be on PrEP if you are HIV-negative). A person who is diligent and courageous in protecting their health is hardly “reckless”.

Further, there has been a bevy of studies that show that PrEP is protective against HIV with or without condoms, and that if someone is HIV-positive and virologically suppressed, they do not transmit HIV. The concept of “recklessness” must change as we learn new ways of preventing HIV transmission.

The claim that there is a spike in sexually transmitted infections (STIs) among young people on PrEP has no basis in data.

In South Africa, there are not enough people on PrEP to draw that conclusion (or at least not enough people whose STI burden we can measure). Further, in settings where STIs among gay men are on the increase, it is not clear that this increase is attributable to expanding PrEP use, or whether STIs are increasing for other reasons.

Large-scale PrEP trials certainly have not found that people who are on PrEP increase their sexual risk. On the contrary, it has been the people who know that they are already at higher risk for HIV who have opted to take PrEP to manage their risk.

Finally, we make a critical omission when we speak about a potential spike in STIs without speaking about the fact that the STIs in question are largely curable, or at least much easier to manage than HIV.

If, as a by-product of protecting people against HIV infection, we end up with more cases of curable STIs, we would still be having a positive effect on people’s lives.

Contracting HIV is no longer a death sentence, but it is a chronic condition that requires strict adherence to the regime of taking daily medication and making regular clinic visits for the rest of one’s life.

In a time when the global HIV epidemic is raging among gay and bisexual men, it is reckless to stigmatise new prevention technologies and the users of these technologies.

It is especially reckless in the South African context to spread misinformation about HIV.

It is not gay men on PrEP who are playing with fire, it is the author of this article and the editors who approved it.

It feels like slut-shaming

Ben van Heerden (via email)

I’m writing in response to an article published on Sunday, March 5 2017, headlined Playing with Fire.

The article is about “reckless sexual behaviour among gay teens and men who are increasingly ditching their condoms, believing their preventive HIV medication will protect them”.

There are several issues with the article:

1. There are not enough people on pre-exposure prophylaxis (PrEP) to draw the conclusion that its use encourages promiscuity. The evidence presented is anecdotal.

2. Even assuming PrEP use does encourage promiscuity, it’s illogical to argue that its use increases the risk exposure of users. By its very design, PrEP reduces the risk of HIV. Of course, there are other ways of reducing risk, like abstaining altogether.

But seriously, this is like arguing that the use of seat belts in cars encourages more driving, thereby increasing risk exposure.

Seat belts, like PrEP, are designed to reduce risk, not increase it. Sure, you can elect to walk (or masturbate), but what about people who want to drive/have sex?

Since there is no logic in this argument, I think it’s coming from a position of moral superiority, as if there is something inherently immoral about promiscuous sex.

It’s sex between two consenting adults, who are taking active steps to reduce their risk exposure. There’s absolutely nothing immoral about this.

3. Lastly, PrEP users are taking active steps to manage their sex lives and their risk exposure. The easy/stupid thing to do would be to simply have unprotected sex without PrEP. It’s cruel to judge people who are taking active control in this way. It feels a lot like slut-shaming.

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